By Counterforce Health Team in Rezlidhia (olutasidenib) —

Getting Rezlidhia (Olutasidenib) Covered by Aetna CVS Health in Virginia: Complete Guide to Prior Authorization, Appeals, and Patient Rights

Answer Box: Your Path to Coverage

Rezlidhia (olutasidenib) requires prior authorization from Aetna CVS Health in Virginia. You're eligible if you have relapsed/refractory AML with a confirmed IDH1 mutation. Fastest path: Have your oncologist submit PA documentation including IDH1 test results, prior treatment history, and medical necessity letter through Aetna's provider portal. Standard approval takes 30-45 days; expedited reviews (for urgent cases) get decisions within 72 hours. If denied, Virginia law gives you strong appeal rights including external review through the State Corporation Commission.

Start today: Contact your oncology team to begin gathering IDH1 mutation test results and prior therapy records.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Clinical Criteria Requirements
  5. Understanding Costs
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy Coordination
  9. Troubleshooting Common Issues
  10. Key Terms Glossary

Coverage Basics

Is Rezlidhia Covered by Aetna CVS Health?

Yes, but with restrictions. Rezlidhia is covered for FDA-approved indications when clinical criteria are met and prior authorization is approved. The drug is typically managed through CVS Caremark specialty pharmacy for Aetna members.

Which Aetna Plans Cover Rezlidhia?

Most Aetna commercial plans, Medicare Advantage, and Medicaid managed care plans include Rezlidhia on their formularies, but it requires prior authorization across all plan types. Coverage specifics vary by your individual plan design.

Note: Self-funded employer plans may have different criteria. Check your Summary of Benefits or contact member services at the number on your insurance card.

Prior Authorization Process

Who Submits the Prior Authorization?

Your oncologist or their staff submits the prior authorization request. Patients cannot submit PA requests directly to Aetna CVS Health.

Step-by-Step: Fastest Path to Approval

  1. Confirm IDH1 mutation testing - Your oncologist orders FDA-approved IDH1 mutation testing (such as the Abbott RealTime IDH1 Assay) if not already completed
  2. Gather treatment history - Clinic documents all prior AML therapies, dates, responses, and reasons for discontinuation
  3. Complete PA forms - Provider completes current Aetna prior authorization form with all required fields and NPI number
  4. Draft medical necessity letter - Oncologist writes detailed letter explaining diagnosis, mutation status, prior treatments, and treatment goals
  5. Submit via provider portal - All documentation submitted through Availity provider portal (preferred method) or fax if necessary
  6. Track submission - Provider records confirmation number and checks status after 5-7 business days
  7. Respond to requests - Quickly provide any additional information Aetna requests during review

Required Documentation Checklist

  • Completed Aetna prior authorization form
  • IDH1 mutation test results from FDA-approved assay
  • Medical necessity letter from board-certified hematologist/oncologist
  • Complete AML treatment history with dates and outcomes
  • Recent lab results (CBC, comprehensive metabolic panel, liver function tests)
  • Current imaging or bone marrow biopsy results
  • Provider credentials and contact information

Timing and Urgency

How Long Does Prior Authorization Take?

  • Standard review: 30-45 days for pre-service requests
  • Expedited review: 72 hours for urgent cases
  • Step therapy override: 72 hours (when applicable)

When to Request Expedited Review

Mark your request as urgent if delays could seriously harm your health. Your oncologist must provide clinical justification for why waiting the standard timeframe would be detrimental.

Tip: For cancer treatments, Virginia law allows expedited external review without completing all internal appeals first.

Clinical Criteria Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
FDA indication Relapsed/refractory AML, age 18+ FDA approval letter
IDH1 mutation Confirmed susceptible IDH1 mutation FDA-approved test results
Specialist prescriber Board-certified hematologist/oncologist Provider credentials
Prior treatments Documented AML treatment history Medical records
Monitoring plan Differentiation syndrome surveillance Treatment protocol

What Counts as Medical Necessity?

According to Aetna's criteria, medical necessity for Rezlidhia requires:

  • Confirmed relapsed or refractory AML diagnosis
  • Positive IDH1 mutation test from approved assay
  • Documentation of prior treatment failures or intolerances
  • Prescriber expertise in AML treatment
  • Plan for monitoring and managing potential side effects

Understanding Costs

Typical Out-of-Pocket Costs

Rezlidhia costs approximately $32,000 per month at list price. Your actual cost depends on your specific plan:

  • Deductible plans: You may pay full cost until meeting your annual deductible ($2,100-$4,200 typical range)
  • Specialty tier copay: Often 20% coinsurance after deductible
  • Medicare Part D: $2,000 annual out-of-pocket maximum starting in 2025

Cost Assistance Options

  • Manufacturer support: Contact Rezlidhia.com for patient assistance programs
  • Medicare Extra Help: Low-income subsidy for Medicare beneficiaries
  • State programs: Contact Virginia Department of Medical Assistance Services for Medicaid-related aid

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Fix It
IDH1 mutation not documented Submit complete FDA-approved test results with clear mutation identification
Non-oncology prescriber Transfer prescription to board-certified hematologist/oncologist
Insufficient prior treatment history Provide detailed records of all AML therapies with dates and outcomes
Missing monitoring plan Include differentiation syndrome monitoring protocol
Non-formulary status Request formulary exception with clinical justification

Appeals Process in Virginia

Internal Appeals (Aetna):

  • Deadline: 180 days from denial notice
  • Standard decision: 30 days (pre-service) or 60 days (post-service)
  • Expedited decision: 72 hours for urgent cases
  • Submit to: Aetna member/provider portal or appeals department

External Review (Virginia State Corporation Commission):

  • When: After Aetna upholds denial (or immediately for cancer treatment denials)
  • Deadline: 120 days from final Aetna denial
  • Decision timeframe: 45 days standard, 72 hours expedited
  • Cost: Free to patients
  • Submit: Form 216-A to Virginia Bureau of Insurance
From our advocates: We've seen many Rezlidhia denials overturned when the appeal includes a comprehensive treatment timeline showing why standard AML therapies failed or caused intolerable side effects. The key is connecting each prior treatment attempt to specific clinical outcomes and explaining why Rezlidhia is the appropriate next step.

Virginia Patient Rights

Virginia law provides strong protections for cancer patients facing insurance denials:

  • Expedited external review available for urgent cancer treatment denials
  • No requirement to exhaust all internal appeals before external review for cancer drugs
  • Independent medical review by board-certified specialists
  • Binding decisions that insurers must follow

Contact Virginia Bureau of Insurance: 1-877-310-6560 for guidance on external review process.

Renewal Requirements

When to Reauthorize

Most Aetna prior authorizations for Rezlidhia are approved for 6-12 months. Your oncologist will receive renewal notices 30-60 days before expiration.

What Changes Trigger New Authorization

  • Change in prescribing physician
  • Dosage modifications
  • Addition of combination therapies
  • Significant changes in clinical status

Specialty Pharmacy Coordination

Why Was My Prescription Transferred?

Aetna typically requires specialty medications like Rezlidhia to be dispensed through CVS Specialty Pharmacy or other approved specialty pharmacies. This ensures:

  • Proper medication handling and storage
  • Clinical monitoring and support
  • Coordination with your insurance benefits

Working with CVS Specialty

  • Delivery: Medications shipped to your home with temperature control
  • Clinical support: Pharmacist consultations on side effects and drug interactions
  • Prior authorization: Specialty pharmacy coordinates with your insurance
  • Financial assistance: Help accessing manufacturer copay programs

Troubleshooting Common Issues

Provider Portal Problems

If your oncologist's office reports portal issues:

  • Verify they're using the current Availity portal for Aetna submissions
  • Confirm all required fields are completed
  • Try fax submission as backup (verify with the source linked below)

Missing Documentation

Common missing items that delay approval:

  • Complete IDH1 mutation test report (not just summary)
  • Detailed prior treatment dates and responses
  • Current performance status assessment
  • Provider NPI and contact information

Status Check Delays

If you haven't heard back within expected timeframes:

  • Contact Aetna member services for status update
  • Ask your provider to call the PA hotline
  • Document all communications with dates and reference numbers

Key Terms Glossary

Prior Authorization (PA): Insurance approval required before coverage begins

Medical Necessity Letter: Detailed clinical justification from your doctor explaining why you need the medication

Step Therapy: Requirement to try less expensive treatments first

Formulary: List of covered medications under your insurance plan

Peer-to-Peer Review: Direct discussion between your doctor and insurance medical director

External Review: Independent evaluation of insurance denials by outside medical experts

When You Need Extra Help

If you're struggling with prior authorization denials or complex appeals, Counterforce Health helps patients and clinicians turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address payers' specific requirements. For complex cases like Rezlidhia approvals, having expert support can make the difference between prolonged delays and timely access to treatment.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with Virginia insurance regulations, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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